Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do more fractionated regimens reduce severe toxicity over SBRT in patients with ILD and early-stage NSCLC?
I personally think fewer fractions are safer, such as 30 Gy x 1 instead of 10 Gy x 5, for patients with advanced COPD or ILD. Why? It's because each time a burst of ionization events is delivered to pulmonary tissues, a wound is created that recruits an inflammatory response, which can exacerbate th...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Should thunderstorm asthma be incorporated into asthma action plans?
Thank you for the ongoing dialogue around thunderstorm-associated respiratory events. These episodes represent not just allergen exposure but a combined aeroallergen–irritant phenomenon involving pollen fragmentation, fungal spore surges, PM2.5 downdrafts, ozone shifts, and the priming effects of pr...
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
What is your working definition of "CPAP failure" - number of weeks, mask trials, structured adherence intervention - before you move a patient to HGNS, OAT, or pharmacotherapy?
I have a hard time with this because my personal definition is not the current definition for payment. However, I try to determine what the patient is willing to accept for therapy before even testing them. I work at the VA, and a lot of the patients have claustrophobia and are, therefore, averse to...
Do you routinely recommend peak flow meters for asthma in your practice?
Always helpful for engaging patient in their own care, and managing exacerbations or fluctuations. Even if patient does not "need" it at first, good to have one on hand, have been trained, and establish good habit.
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...